Fillable APPLICATION FOR CHANGE OF NAME (ADULT) Rockingham (County of Rockingham)

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APPLICATION FOR CHANGE OF NAME (ADULT) Rockingham (County of Rockingham)

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BROWSE COUNTY OF ROCKINGHAM (VA) FORMS

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FORM CC-1411 (MASTER, PAGE ONE OF TWO) 07/18

APPLICATION FOR CHANGE OF NAME (ADULT)

COMMONWEALTH OF VIRGINIA VA. CODE § 8.01-217

VIRGINIA: In the Circuit Court of the

[ ] City [ ] County of .....................................................................................

IN RE:

...................................................................................................................................................................

(APPLICANT’S PRESENT NAME) FIRST MIDDLE LAST SUFFIX

COMES NOW, the applicant, ........................................................................................................................

and after being duly sworn states under oath as follows:

1. Applicant’s Birth Name:

.....................................................................................................................................

FIRST MIDDLE LAST SUFFIX

2. City or County of Residence: ...............................................................................................................................

3. Residence Address: ............................................................................................................................................

STREET ADDRESS

........................................................................................................................................................................

CITY STATE ZIP CODE COUNTRY

4. Mailing Address: ...............................................................................................................................................

IF DIFFERENT FROM RESIDENCE ADDRESS

5a. Date of Birth: ........................................................... 5b. Place of Birth: .............................................................

6. Full Names of Parents

6a. Full Name:

........................................................................................................................................................

FIRST MIDDLE MAIDEN (IF APPLICABLE) CURRENT LAST SUFFIX

6b. Full Name: ........................................................................................................................................................

FIRST MIDDLE MAIDEN (IF APPLICABLE) CURRENT LAST SUFFIX

7. Reason for name change application:

[ ] Supplemental sheet attached

Answer the following questions by checking appropriate “Yes” or “No” box and providing information as requested.

8. Have you ever been convicted of a felony?

................................................................................ [ ] Yes [ ] No

9. Are you currently incarcerated?

......................................................................................... [ ] Yes [ ] No

If yes, indicate facility name and location:

...........................................................................................................

If yes, indicate name(s) of court(s) where convicted: .............................................................................................

10. Are you a probationer with any court(s)? ** ............................................................................. [ ] Yes [ ] No

If yes, indicate court(s) name:

.............................................................................................................................

........................................................................................................................................................................

11. Are you a person for whom registration with the Sex Offender and

[ ] Yes [ ] No

Crimes Against Minors Registry is required? **

If yes, indicate court(s) where conviction occurred that resulted in the requirement to register:

.....................................

........................................................................................................................................................................

12. Have you previously changed your name either by a prior application or by marriage? [ ] Yes [ ] No

(If yes, attach court order or other documentation and indicate previous names):

........................................................................................................................................................................

** No application of a probationer, incarcerated person, or person for whom registration with the Sex Offender and Crimes

Against Minors Registry is required shall be accepted unless the Court finds good cause exists for such application under the

reasons alleged in the application for the requested change of name. Attach explanatory documentation to the application.

........................................................................................................................................................................

....................................................................................................................

Rockingham

Print Form

WHEREFORE, the undersigned applicant further certifies under oath that this name change is not sought for any

fraudulent purposes and will not infringe upon the rights of others, and pursuant to § 8.01-217 of the Code of Virginia, 1950,

as amended, the applicant requests that the Court order a change of name from:

........................................................................................................................................................................

FIRST MIDDLE LAST SUFFIX

........................................................................................................................................................................

FIRST MIDDLE LAST SUFFIX

______________________________________________________________

APPLICANT

Commonwealth/State of

..............................................................

[ ] City [ ] County of ........................................................

Subscribed and sworn to/affirmed before me this .................. day of ................................................., 20 ..................

by ...................................................................................................................................................................

....................................................... ______________________________________________________________

DATE

[ ] CLERK [ ] DEPUTY CLERK

[ ] NOTARY PUBLIC My commission expires ............................

Registration No. ....................................

FORM CC-1411 (MASTER, PAGE TWO OF TWO) 11/11

ORDER FOR CHANGE OF NAME (ADULT) Case No. .......................................................

Commonwealth of Virginia VA. CODE §§ 8.01-217, 20-121.4

VIRGINIA: In the Circuit Court of the [ ] City [ ] County of .........................................................................................

In re:

This day came the applicant having filed his/her verified application requesting the change of his/her name from

....................................................................................................................................................................................

FIRST MIDDLE LAST SUFFIX

....................................................................................................................................................................................

FIRST MIDDLE LAST SUFFIX

Additional former name(s) of the applicant: ......................................................................................................................

The applicant’s address is:

.............................................................................................................................................

[ ] The Court finds that

[ ] the application complies with the requirements of subsection B of Virginia Code § 8.01-217,

[ ] a motion was made pursuant to Va. Code § 20-121.4 incident to divorce,

the change of name is not sought for any fraudulent purpose, and the change of name would not otherwise infringe

upon the rights of others.

[ ] The Court previously found that the applicant is presently incarcerated, a probationer, or a person for whom registration

with the Sex Offender and Crimes Against Minors Registry is required but found good cause for consideration of the

application and conducted a hearing on the application.

[ ] The Court finds that the change of name would not frustrate a legitimate law enforcement purpose, is not sought

for a fraudulent purpose, and would not otherwise infringe upon the rights of others. The basis for this finding is as

follows:

.....................................................................................................................................................

..................................................................................................................................................................

Accordingly, it is ADJUDGED and ORDERED that

[ ] The applicant’s name is hereby changed, effective this date, to

....................................................................................................................................................................................

and this cause is ended.

[ ] The Clerk of this Court shall forthwith spread this Order upon the current deed book, indexing the order in both the old and

new names.

[ ] The Clerk of this Court shall further transmit a certified copy of this Order and the application to the State Registrar of Vital

Records and to the Central Criminal Records Exchange.

[ ] This change of name is granted incident to a divorce and the Clerk shall not transmit any copy of this Order to the Registrar

of Vital Records or to the Central Criminal Records Exchange.

[ ] Public recording of the name change would pose a serious threat to the health or safety of the applicant/applicant’s family

and the record of this cause is hereby Ordered sealed. The Clerk shall not spread or index this Order and shall not transmit

any copy of this Order to the Registrar of Vital Records or to the Central Criminal Records Exchange.

[ ] The application for change of name is hereby denied and this cause is dismissed.

Entered this ........................ day of ......................................................................, 20 ..............................

_____________________________________________________________________

JUDGE

FORM CC-1412 MASTER 07/14

Rockingham

FORM CC-1416 (MASTER) PAGE ONE 07/16

COVER SHEET FOR FILING CIVIL ACTIONS Case No. .............................................................................

COMMONWEALTH OF VIRGINIA (CLERK’S OFFICE USE ONLY)

........................................................................................................................................................................................................................... Circuit Court

............................................................................................................................... v./In re: ......................................................................................................................

PLAINTIFF(S) DEFENDANT(S)

............................................................................................................................... ......................................................................................................................

I, the undersigned [ ] plaintiff [ ] defendant [ ] attorney for [ ] plaintiff [ ] defendant hereby notify the Clerk of Court that I am filing

the following civil action. (Please indicate by checking box that most closely identifies the claim being asserted or relief sought.)

GENERAL CIVIL

Subsequent Actions

[ ] Claim Impleading Third Party Defendant

[ ] Monetary Damages

[ ] No Monetary Damages

[ ] Counterclaim

[ ] Monetary Damages

[ ] No Monetary Damages

[ ] Cross Claim

[ ] Interpleader

[ ] Reinstatement (other than divorce or

driving privileges)

[ ] Removal of Case to Federal Court

Business & Contract

[ ] Attachment

[ ] Confessed Judgment

[ ] Contract Action

[ ] Contract Specific Performance

[ ] Detinue

[ ] Garnishment

Property

[ ] Annexation

[ ] Condemnation

[ ] Ejectment

[ ] Encumber/Sell Real Estate

[ ] Enforce Vendor’s Lien

[ ] Escheatment

[ ] Establish Boundaries

[ ] Landlord/Tenant

[ ] Unlawful Detainer

[ ] Mechanics Lien

[ ] Partition

[ ] Quiet Title

[ ] Termination of Mineral Rights

Tort

[ ] Asbestos Litigation

[ ] Compromise Settlement

[ ] Intentional Tort

[ ] Medical Malpractice

[ ] Motor Vehicle Tort

[ ] Product Liability

[ ] Wrongful Death

[ ] Other General Tort Liability

ADMINISTRATIVE LAW

[ ] Appeal/Judicial Review of Decision of

(select one)

[ ] ABC Board

[ ] Board of Zoning

[ ] Compensation Board

[ ] DMV License Suspension

[ ] Employee Grievance Decision

[ ] Employment Commission

[ ] Local Government

[ ] Marine Resources Commission

[ ] School Board

[ ] Voter Registration

[ ] Other Administrative Appeal

DOMESTIC/FAMILY

[ ] Adoption

[ ] Adoption – Foreign

[ ] Adult Protection

[ ] Annulment

[ ] Annulment – Counterclaim/Responsive

Pleading

[ ] Child Abuse and Neglect – Unfounded

Complaint

[ ] Civil Contempt

[ ] Divorce (select one)

[ ] Complaint – Contested*

[ ] Complaint – Uncontested*

[ ] Counterclaim/Responsive Pleading

[ ] Reinstatement –

Custody/Visitation/Support/Equitable

Distribution

[ ] Separate Maintenance

[ ] Separate Maintenance Counterclaim

WRITS

[ ] Certiorari

[ ] Habeas Corpus

[ ] Mandamus

[ ] Prohibition

[ ] Quo Warranto

PROBATE/WILLS AND TRUSTS

[ ] Accounting

[ ] Aid and Guidance

[ ] Appointment (select one)

[ ] Guardian/Conservator

[ ] Standby Guardian/Conservator

[ ] Custodian/Successor Custodian (UTMA)

[ ] Trust (select one)

[ ] Impress/Declare/Create

[ ] Reformation

[ ] Will (select one)

[ ] Construe

[ ] Contested

MISCELLANEOUS

[ ] Amend Death Certificate

[ ] Appointment (select one)

[ ] Church Trustee

[ ] Conservator of Peace

[ ] Marriage Celebrant

[ ] Approval of Transfer of Structured

Settlement

[ ] Bond Forfeiture Appeal

[ ] Declaratory Judgment

[ ] Declare Death

[ ] Driving Privileges (select one)

[ ] Reinstatement pursuant to § 46.2-427

[ ] Restoration – Habitual Offender or 3

Offense

[ ] Expungement

[ ] Firearms Rights – Restoration

[ ] Forfeiture of Property or Money

[ ] Freedom of Information

[ ] Injunction

[ ] Interdiction

[ ] In

terrogatory

[ ] Judgment Lien-Bill to Enforce

[ ] Law Enforcement/Public Official Petition

[ ] Name Change

[ ] Referendum Elections

[ ] Sever Order

[ ] Taxes (select one)

[ ] Correct Erroneous State/Local

[ ] Delinquent

[ ] Vehicle Confiscation

[ ] Voting Rights – Restoration

[ ] Other (please specify)

............................................................................

...................................................................... ____________________________________________________________________

DATE [ ] PLAINTIFF [ ] DEFENDANT [ ] ATTORNEY FOR [ ] PLAINTIFF

[ ] DEFENDANT

............................................................................................................................................

PRINT NAME

............................................................................................................................................

ADDRESS/TELEPHONE NUMBER OF SIGNATOR

............................................................................................................................................

EMAIL ADDRESS OF SIGNATOR (OPTIONAL)

*“Contested” divorce means any of the following matters are in

dispute: grounds of divorce, spousal support and maintenance,

child custody and/or visitation, child support, property distribution

or debt allocation. An “Uncontested” divorce is filed on no fault

grounds and none of the above issues are in dispute.

[ ] Damages in the amount of $

............................................................... are claimed.

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